the effects of shortterm physical therapy and education on early functional recovery of the patients younger than undergoing total hip arthroplasty
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Slide 1 :
The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty Vukomanovic A, Popovic Z, Djurovic A, Krstic Lj Military Medical Academy, Belgrade, Serbia firstname.lastname@example.org Vojnosanit Pregl 2008; 65(4): 291-7
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The role of physical therapy and education after hip arthroplasty was recognized1, but the importance of pre-operative physical therapy and education is still to be judged2-4. 1. Bitar AA, Kaplan RJ, Stitik TP, Shih VC, Vo AN, Kamen BK. Rehabilitation of orthropedic and rheumatological disorders. 3. Total hip arthroplasty rehabilitation. Arch Phys Med Rehabil 2005; 86 (suppl 1): S56 – 60. 2. Ackerman IN, Bennell KL. Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic rewiew. Australian Journal of Physiotherapy 2004; 50: 25-30. 3. Mc Donald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. The Cochrane Database of Systematic Reviews 2004 Issue 1. 4. Johansson K, Liisamaija N, Heli V, Jouko K, Salanterä S. Preoperative education for orthopaedic patients: systematic review. Journal of Advanced Nursing 2005; 50 (2): 212-23.
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Pre-operative physical therapy? Wijgman AJ, Dekkers GH, Waltje E, Krekels T, Arsens H. No positive effects of preoperative exercise therapy and teaching in patients to be subjected to hip arthroplasty. Ned Tijdschr Geneeskd 1994; 138: 949-52. (In Dutch). Gilbey HJ, Ackland TR Wang AW, Morton AR, Tapper J. Exercise improves early functional recovery after total hip arthroplasty. Clin Orthop 2003; 408: 193-200. Gocen Z, Sen A, Unver B, Karatosun V, Gunal I. The effect of preoperative physiotherapy and education on the outcome of total hip replacement: a prospective randomized controlled trial. Clin Rehabil 2004 Jun; 18 (4): 353-8. Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE, Alpert S, Iverson MD, Katz JN. Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis Rheum 2006 Oct 15; 55(5): 700-8. There is not strong evidence that continuous pre-operative physical therapy alone brings significant benefits to patients’ functional recovery immediately after operation. yes yes no no
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But we still don’t know much about effects of education pre-operative programs on patients’ ability to perform basic activities of daily living safely and independently on the discharge from the orthopedic unit. Pre-operative programs of education appear to have been effective in reducing pre-operative anxiety, pain1 and shortening the hospital stay2-6. A considerable reduction in length of hospital stay results in a significant cost saving1,7. 1. Giraudet – Le Quintrec JS, Coste J, Vastel L, Pacault V, Jeanne L, Lamas JP, Kerboull L, Fougeray M, Conseiller C, Kohan A, Courpied JP. Positive effect of of patient education for hip surgery: a randomized trail. Clin Orthop 2003; 414: 112-120. 2. Mc Gregor AH, Rylands H, Owen A, Dore CJ, Hughes SPF. Does preoperative advice improve recovery and patient satisfaction? J Arthroplasty 2004; 19: 464-8. 3. Siggeirsdottir K, Olafsson O, Jonsson H, Iwarsson S, Gudnason V, Jonsson BY. Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement. Acta Orthopaedica 2005; 76 (4): 555 – 62. 4. Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Can J Occup Ther 2003; 70 (2): 88 – 96. 5. Weingarten S, Riedinger MS, Sandhu M, Browers C, Elldort G, Nunn C, Hobson P, Greengold N. Can practice guidelines safely reduce hospital stay? Results from a multicenter interventional study. Am J Med 1998; 105: 33 – 40. 6. Fisher DA, Trimble S, Clapp B, Dorsett K. Effect of a patient management system on outcomes of total hip and knee arthroplasty. Clin Orthop 1997; 345: 155 – 60. 7. Brunenberg DE, van Steyn MJ, Sluimer JC, Bekebrede LL, Bulstra SK, Joore MA. Joint Recovery Programme versus usual care: An economic evaluation of a clinical pathway for joint replacement surgery. Medical Care 2005; 43(10):1018 – 26. Pre-operative education?
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The aim of this study was to examine effects of short-term preoperative program of education and physical therapy on patients’ early functional recovery immediately after hip arthroplasty. In clinical practice, we observed that patients mostly benefited from pre-operative program of education and physical therapy immediately after operation. But not a single study investigates the acceleration of patients’ functional recovery in that period. AIM
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Forty-five patients admitted to Department of orthopedics scheduled to undergo primary total hip replacement who satisfied our eligibility criteria were recruited into this study at the authors’ institution. Eligible patients were: (1) with primary and secondary osteoarthritis, (2) aged 70 and younger, (3) who gave informed consent to participate in investigation. Additional eligibility criteria included: (4) ability to walk up and down stairs, (5) no need for using crutches while walking, (6) no experience in walking whit crutches (because of opposite hip arthroplasty or some other reasons) and (7) no coexisting morbidity such as a history of severe cardiovascular, respiratory, neuromuscular, rheumatic disease or mentally confusion. Reasons for exclusion patients through the trail were appearance of: (1) intraoperative (femoral or acetabular fracture) or (2) postoperative complications (postoperative disorientation, anemia, circulatory collapse, orthostatic hypotension, chest pain, sustained hypertension, deep venous thrombosis, pulmonary embolism, hip dislocation) which compromised or delayed beginning of physical therapy after operation. METHODS SUBJECTS
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The patients were randomly divided into two groups. Study group received short-term intensive preoperative preparation which consisted of education and elements of physical therapy. Patients from the study group were informed about operation, caution measures and rehabilitation after arthroplasty through conversation with physiatrist and brochure. They were instructed by physiotherapist to perform exercises and basic activities from the postoperative rehabilitation program, such as bed mobility, getting out and in bed, standing and walking with crutches, use of toilet, sitting on chair, walking up and down stairs with aids. The study group had 1 appointment with physiatrist and 2 practical classes with physiotherapist. Control group didn’t receive preoperative education and physical therapy, but both groups had the same program of rehabilitation after arthroplasty. Program of rehabilitation for patients of both groups started on the first day after operation. METHODS INTERVENTIONS
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Patient’s ability to perform nine basic activities and endurance were evaluated at the end of every day of rehabilitation program during hospital stay on Department of orthopedics. Visual analog scale (VAS), 0 – 100 mm, was used for the assessment of pain while moving and in the rest. Range of motion (flexion of the hip with flexed knee, flexion of the hip with extended knee, abduction) was measured with goniometry. Harris hip score, hip score of the Japanese Orthopaedic Association (JOA) and Oxford hip score were used for the assessment of functional status. All patients were evaluated at admission, discharge and 15 months after operation (Oxford hip score). METHODS OUTCOMES MEASURES
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Marks showing ability to perform activity were: 0 – if patient didn’t perform activity, 1 – if patient was absolutely dependent of therapist help, 2 – if patient performed activity with little therapist help, 3 – patient needed therapist’ verbal suggestion while performing activity, 4 – patient performed activity independently but insecurely (needed presence of another person, member of family for example), 5 – patient performed activity independently and securely. Marks showing endurance were: 0 – didn’t walk, 1 – walked 5 meters (in bed room), 2 – walked 15 meters, 3 – walked 50 meters, 4 – walked 100 meters, 5 – walked more than 100 meters. METHODS OUTCOMES MEASURES 0 1 2 3 4 5 0 1 2 3 4 5
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Protocol for assessment patient’s ability to perform basic activities from program of rehabilitation after total hip arhroplasty 0 2 19 1 1 2 2 2 2 3 4 METHODS OUTCOMES MEASURES 4 4 4 4 4 4 5 5 4 2 40 50 5 5 5 5 5 5 5 5 5 5
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All analyses were performed using SPSS software, version 10.0. Fisher Exact Test, Pearson Chi-squared Test, Mann Whitney Exact Test were used for comparison between groups. Distribution of variables was shown as mean, standard deviation, medians, range, p – values less than 0.05 were accepted as significant. METHODS STATISTICAL ANALYSIS
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Preoperative characteristics of study participants Values are mean ± standard deviation, median (range) unless otherwise indicated. RESULTS
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Pain on the admission (VAS) p=0.66 p=0.70 Mann Whitney Exact Test mm RESULTS
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Abduction and flexion of the hip with flexed and extended knee on the admission, degrees degrees P=0.19 n.s. p=0.30 n.s. p=0.37 n.s. Mann Whitney Exact Test RESULTS
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Haris, JOA, Oxford on the admission p=0.03 p < 0.05 p=0.17 n.s. p=0.55 n.s. RESULTS Participants from the study group had statistically higher Oxford hip score before operation. That result suggested worse functional status of the study group at the baseline. But, for the assessment of the functional status we also used Harris and JOA hip scores and then there were no differences between groups at baseline.
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The first days of activities Values are mean ± standard deviation, median (range).* Significant values The first day patients could stand, walk, climb a stair was one of the parameters which could be compared. Gocen et al. found that patients in the study group performed transfer activities earlier than the control group, but that was not case in Wijgmans study. Results of our trail showed that both groups started walking at the same time, but the study group used toilet and chair, walked up and down stairs earlier than the control group.
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Comment It is important when the patient starts doing these activities, but it is more important when that patient becomes independent and secure in performing these activities. Those data were not available in other studies. In our study, every day during hospital stay, a physiotherapist assessed patients’ ability to perform some basic activities using marks from 0 to 5. Mark 4 meaned the first degree of independence; patient could do activity alone, without help or verbal suggestion of physiotherapist. Already from the third day after operation, the study group had mean mark higher than 4 for changing position in bed, getting out and in bed, standing and walking. They trained all basic activities until discharge and went home absolutely independently and mostly securely. Some patients from the control group were insecure on the discharge, and, for some activities, they depended from the help of physiotherapist. So, mean marks of the control group were significantly worse at the moment of discharge. RESULTS
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1. FROM SUPINE TO SIDE LYING mark Day of physical therapy Mann Whitney Exact Test p < 0.05 p < 0.01 p < 0.01 p=0.08
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2. FROM SUPINE TO SITTING mark Day of physical therapy p < 0.01 p < 0.05 p < 0.01 p < 0.05 Mann Whitney Exact Test
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3. FROM SITTING TO STANDING mark Day of physical therapy p < 0.01 p < 0.01 p < 0.01 p < 0.05 Mann Whitney Exact Test
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4. STANDING mark Day of physical therapy p < 0.01 p < 0.01 p < 0.01 p < 0.05 Mann Whitney Exact Test
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5. BACK TO BED FROM THE STANDING POSITION mark Day of physical therapy p < 0.05 p < 0.01 p < 0.01 p < 0.05 Mann Whitney Exact Test
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6. WALKING WITH CRUCHES mark Day of physical therapy p < 0.05 p < 0.01 p < 0.01 p < 0.05 Mann Whitney Exact Test
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7. USE OF TOALET mark Day of physical therapy Mann Whitney Exact Test n.s. n.s. p < 0.01 p < 0.05
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mark Day of physical therapy Mann Whitney Exact Test 8. SITTING ON CHAIR n.s. p < 0.01 p < 0.01 p < 0.01
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9. WALKING UP AND DOWN STAIRS mark Day of physical therapy Mann Whitney Exact Test n.s. p < 0.05 p < 0.01 p < 0.001 Walking up and down stairs was the heaviest activity from the program of the physical therapy. We calculated that on the way from hospital to patient’s home, patient had to climb up average 12 – 13 steps. So, it’s important for them to overcome stairs during hospital stay. Patients from the study group could do it without any problems but patients from the control group mainly still needed help and suggestions from the physiotherapist.
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10. ENDURANCE WHILE WALKING mark Day of physical therapy Mann Whitney Exact Test p < 0.05 p < 0.01 p < 0.01 p < 0.01
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Haris, JOA on the discharge, Oxford 15 months after operation Mann Whitney Exact Test n.s. n.s. n.s. Harris and JOA hip score can successfully measure remote effects of hip arthroplasty but maybe they are not sensitive enough to measure effects of preoperative physical therapy and education at the time of discharge from the orthopedic unit. Of course, this state needs to be investigated in another study.
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Pain on the discharge(VAS) Mann Whitney Exact Test mm p=0.66 n.s. p=0.66 n.s. Giraudet – Le Quintrec et al. found that patient education decreased preoperative anxiety and pain in patients having hip surgery. Unfortunately we can’t confirm those results. Before the operation, participants from both groups had intensive pain while moving which diminished in the rest but not completely. On discharge, we can notice that mean of pain assessed by VAS decreased in both groups. But there were no differences between groups neither before nor after the operation.
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Length of hospital stay and physical therapy after operation Mann Whitney Exact Test n.s. p < 0.01 day The study group achieved goals of early postoperative physical therapy earlier and they needed fewer classes with physiotherapist. Length of hospital stay didn’t differ between the groups because the moment of discharge is mostly planned according to wound healing (10 or 11 day after operation) and functional recovery didn’t influence that.
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Comment In view of world’s growing tendency for reducing health care costs and unconvincing effects of continuous preoperative physical therapy we created a short-term pre-operative program of education with elements of physical therapy. This preoperative program helped patient scheduled for arthroplasty to overcome basic activities of daily living with minimum practical classes of physical therapy after operation. These results were gained from 1 appointment with physiatrist, 2 practical classes with physiotherapist and from reading brochure with information about arthroplasty and recovery after operation. We practiced this preoperative program after admission on orthopedic unit, but it can be perform like an outpatient activity.
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CONCLUSION The short-term preoperative program of education with elements of physical therapy, presented in this issue, accelerated early functional recovery of patients (younger than 70) immediately after total hip arthroplasty. On the third day after operation, they were able to change position in bed, get out and in bed, stand up and walk independently. On the discharge they could use toilet and sit on chair, walk up and down stair without help of physiotherapist. Their endurance while walking was significantly better than the control group. Patients, who were educated and instructed postoperatively, achieved better functional outcome on discharge with significantly less classes with therapist during hospital stay. Their functional level on discharge didn’t require further engagement of physiotherapist. The short-term preoperative program of education with elements of physical therapy is useful for patients undergoing total hip arthroplasty and we recommend it for routine use.
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